HomeMy WebLinkAboutApplication0 Stream or Creek ❑ Cistern
Garfield County
'Community Development Department
108 8th Street, Suite 401
MAR 16 ZOl%Glenwood Springs, CO 81601
(970) 945-8212
www.garfield-countv.com
ONSITE WASTEWATER
TREATMENT SYSTEM
(OWTS)
PERMIT APPLICATION
TYPE OF CONSTRUCTION
Property Owner: Si '' i I 8 ► Phone: (Li7() ) 519 . 4 261, 2
Mailing Address: 16706 fl I9(1IN61)1 'Z Ca,r"boii 'aJe, CO '31623
Email Address: 0 b (/Lrc1, C k r1.0 . C o m
• New Installation
Contractor: —7_ �.wwOy' 'x cc, c.),..0• 11v Phone: ( Q 7p) 4Pz,_ - Ririe
•
Alteration
Repair
WASTE TYPE
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
j, Dwelling '
• Transient Use
239 / - 3 �'S�ut. 3�� 32- 7- 3 7R Lot) 3 lock
! • Comm./Industrial
• Non -Domestic
4 Garbage Disposal NG
Sewer System:
connect to the Community
RQ oC)
WOGt.ri r ? 3 f " Ute"
Sewer System:
• Other Describe
Type of OWTS
g Septic Tank 0 Aeration
❑ Recycling, Potable Use
Plant 0 Vault
0 Vault Privy
INVOLVED PARTIES sk.I r1}' q 70 261. 00
Final
Property Owner: Si '' i I 8 ► Phone: (Li7() ) 519 . 4 261, 2
Mailing Address: 16706 fl I9(1IN61)1 'Z Ca,r"boii 'aJe, CO '31623
Email Address: 0 b (/Lrc1, C k r1.0 . C o m
Contractor: —7_ �.wwOy' 'x cc, c.),..0• 11v Phone: ( Q 7p) 4Pz,_ - Ririe
Mailing Address: / 7 Lf 6,`q h „._,,,y. ' c C��'or+sJ.d. 6_ c 70 3?' 71 nEmail
Address: VV
Engineer: Phone: ( )
Mailing Address:
Email Address:
PROJECT NAME AND LOCATION
Job Address: I (o1 (a +-il h W C _ 462 , Cor bomci ce. I e , Co � 1(1) 2
Assessor's Parcel Number:
Building or Service Type:
Distance to Nearest Community
Was an effort made to
239 / - 3 �'S�ut. 3�� 32- 7- 3 7R Lot) 3 lock
G�. rG+,9 #Bedrooms:
' (2-±
4 Garbage Disposal NG
Sewer System:
connect to the Community
RQ oC)
WOGt.ri r ? 3 f " Ute"
Sewer System:
N 0
Type of OWTS
g Septic Tank 0 Aeration
❑ Recycling, Potable Use
Plant 0 Vault
0 Vault Privy
0 Composting Toilet
0 Recycling
0 Pit
Privy 1 Incineration
Toilet
❑ Chemical Toilet
1 0 Other
Ground Conditions
Depth to 15t Ground water table
0
I Percent Ground Slope
til xi---
fi
Final Disposal by
Absorption trench, Bed or Pit 0 Underground Dispersal I 0 Above Ground Dispersal
O Evapotranspiration
0 Wastewater Pond
0 Sand Filter
O Other
Water Source & Type --pc well
0 Spring
O Community Water System Name
Effluent
CERTIFICATION
Will Effluent be discharged directly into waters of the State?
❑ Yes No
Applicant acknowledges that the completeness of the application is conditional upon such further
mandatory and additional test and reports as may be required by the local health department to be
made and furnished by the applicant or by the local health department for purposed of the evaluation
of the application; and the issuance of the permit is subject to such terms and conditions as deemed
necessary to insure compliance with rules and regulations made, information and reports submitted
herewith and required to be submitted by the applicant are or will be represented to be true and
correct to the best of my knowledge and belief and are designed to be relied on by the local
department of health in evaluating the same for purposes of issuing the permit applied for herein. I
further understand that any falsification or misrepresentation may result in the denial of the
application or revocation of any permit granted based upon said application and legal action for perjury
as provided by law.
I hereby acknowledge that I have read and understand the Notice and Certification above as well as
have provided the required information Which is correct and accurate to the best of my knowledge.
1A-., car c
3 I6, 2O/
Amy I. f'rd[ck
)k1 1 iv -
Property Owner Print and Sign
Date
OFFICIAL USE ONLY
Special Conditions:
PgrA Fee: co
Perk Fee: ATotal
Permit:
Fees: -1 -
Fee aid:cc
Building Permit
‘•_
Septic
-1.-`t (o
Issueate:(
?,-2-ol -24.71---9-
2O1 Th
Balance Due:
0
BLDG DIV:
3P17'
-'/
A" ROVA DATE
/